bedlam on the streets: a classic in mental health

Increasingly, the mentally ill have nowhere to go. That’s their problem and ours.

By MICHAEL WINERIP

New York Times, May 23, 1999, p. 42

Maybe they should have just stenciled it in large letters on Andrew Goldstein’s forehead: “TICKING TIME BOMB. SUFFERS SCHIZOPHRENIA. IF OFF MEDICATION, RUN FOR COVER!” The news accounts of his arrest for pushing Kendra Webdale under a subway train in New York that first Sunday afternoon in January must have sent a cold shiver through the hundreds of psychiatrists, therapists and social workers who had treated this seriously mentally ill man.

They knew he was dangerous. In the two years before Kendra Webdale was instantly killed on the tracks, Andrew Goldstein attacked at least 13 other people. The hospital staff members who kept treating and discharging Goldstein knew that he repeatedly attacked strangers in public places. They knew because he had attacked them — two psychiatrists, a nurse, a social worker and a therapy aide in two years’ time. Over and over, his hospital charts carried warnings.

5/6/98: High risk for violence. 7/31/98: Last 6-12 months patient has been acting aggressively and impulsively by striking out unprovoked.

They knew. Long before this subway push and another one last month, the state of the nation’s shattered mental-health system all but assured such calamities. Yet for each hospitalization — there were 13 in 1997 and 1998 alone — Goldstein was given medication, then discharged, often after just a few days, to live on his own in a basement apartment. And now the consequences were front-page news: “Horror on the Tracks,” read the tabloid headlines, “The Face of a Madman.”

They knew. He was hospitalized after assaulting a psychiatrist at a Queens clinic. 11/14/97: Suddenly, without any warning, patient springs up and attacks one of doctors, pushing her into a door and then onto the floor. He was hospitalized after threatening a woman at a Waldbaum’s supermarket; after attacking two strangers at a Burger King; after fighting with an apartment mate. 3/2/98: Broke down roommate’s door because he could not control the impulse. And particularly chilling, six months before Kendra Webdale’s death, he was hospitalized for striking another woman he did not know on a New York subway. 6/20/98: Brought to E.R. by E.M.S. after patient lost motor control and punched a girl on the subway.

Sometimes he was delivered to the hospitals by well-meaning police officers trying to get him treatment. More often, Goldstein walked into the psychiatric E.R. on his own, seeking help. This 29-year-old Jewish male (as the records describe him), who before schizophrenia set in had been so bright that he graduated from Bronx High School of Science, one of the city’s elite public high schools, now was repeatedly explaining to E.R. doctors that he was confused or couldn’t remember how to get home or that his brain had stopped working.

Six weeks before Webdale, on Nov. 20, 1998, he arrived at Jamaica Hospital in Queens, again asking to be hospitalized. Walked in the E.R. complaining of hearing voices, people following him and being inhabited by people. … They removed my brain, I don’t know why. I am hearing these voices telling me something will happen. … I cannot cope.”

How psychotic was Goldstein when he was off his medicine? At various times, he has told psychiatrists that he was turning purple, that he had shrunk six to eight inches, that he had lost his neck, had developed an oversize penis because of contaminated food and that a homosexual man named Larry was stealing his excrement from the toilet “through interpolation” then eating it with a knife and fork. The voices seemed so real, so relentless, that on Nov. 24 a psychiatrist wrote, “He requested eyeglasses so that he will find the people talking to him.”

He Wanted Help

When a mental patient kills, there is often an outcry for tougher commitment laws, but this was not the problem in Goldstein’s case. He signed himself in voluntarily for all 13 of his hospitalizations. His problem was what happened after discharge. The social workers assigned to plan his release knew he shouldn’t have been living on his own, and so did Goldstein, but everywhere they looked they were turned down. They found waiting lists for long-term care at state hospitals, waiting lists for supervised housing at state-financed group homes, waiting lists for a state-financed intensive-case manager, who would have visited Goldstein daily at his apartment to make sure he was coping and taking his meds.

More than once he requested long-term hospitalization at Creedmoor, the state hospital nearby. In 1997, he walked into the Creedmoor lobby, asking to be admitted. “I want to be hospitalized,” he said. “I need a placement.” But in a cost-cutting drive, New York has been pushing hard to reduce its patient census and to shut state hospitals. Goldstein was instead referred to an emergency room, where he stayed overnight and was released.

Again, in July 1998, Goldstein cooperated with psychiatrists, this time during a monthlong stay at Brookdale Hospital, in hopes of getting long-term care at Creedmoor. Brookdale psychiatrists had a well-documented case. In a month’s time, Goldstein committed three violent acts: punching the young woman on the subway; attacking a Brookdale therapist, a psychiatrist, a social worker and a ward aide; striking a Brookdale nurse in the face. This time, Creedmoor officials agreed in principle to take him, but explained that there was a waiting list, that they were under orders to give priority to mental patients from prison and that they did not know when they would have an opening. Days later, Goldstein was discharged from Brookdale.

Another reasonable alternative would have been a supervised group home or single-room-occupancy hotel staffed by counselors around the clock. Goldstein repeatedly asked for such a placement, but openings are rare, since Gov. George Pataki financed no new supervised community residences for the mentally ill during his first four-year term and just 200 S.R.O. beds statewide. “Working on getting him a residence in Manhattan within the next three to six months,” says a Dec. 16, 1998, note, 18 days before he pushed Webdale.

At the very least, Goldstein should have had an intensive-case manager, a state-financed caseworker whose job would have been to visit him daily at his apartment. On Dec. 11, 1998 — 23 days before Webdale — a North General Hospital social worker wrote that an intensive-case manager was needed, because “patient is unable to manage his money, does not take care of himself and becomes noncompliant with meds.” But that waiting list was months long, too.

Goldstein’s last hospitalization before Webdale was at North General, from Nov. 24 to Dec. 15. Because of cost-saving measures mandated under managed care, hospitals that operate short-term, or “acute care,” psychiatric units are under great financial pressure to discharge patients within three weeks. So two weeks into his stay, on Dec. 9, even as Goldstein was still being described by North General’s psychiatrist as “disorganized, thought-disordered . . . talking to himself … very delusional,” the discharge team had already set his release for the next week.

Sure enough, on Dec. 15, North General discharged Goldstein with a week’s supply of medicine and a form advising him to report to Bleuler Psychotherapy Center for counseling. This was like a bad joke — that a man so sick, with his history, would be sent into the community with so little support. At clinics like Bleuler, state financing is minimal. Social workers have large caseloads with no time to visit clients. Since September, Bleuler had supposedly been treating Goldstein, but he had missed most of his appointments and had repeatedly gone off his meds.

It happened again: he missed two clinic appointments in late December. He stopped taking his medication. If he had had an intensive-case manager or a group-home counselor, or both, it would have been their job to find him and see what was wrong. At Bleuler, it wasn’t anyone’s job. Instead, on Dec. 26, a Bleuler worker mailed a form letter requesting that Goldstein phone the clinic by Jan. 6, 1999, or else his case would be closed.

On Jan. 3, 1999, at 5:06 P.M., the N train pulled into the station at 23d Street and Broadway. Kendra Webdale was a vivacious 32-year-old who had come to the city three years before from upstate and was working as a receptionist with dreams of landing a big job in the music industry. To Andrew Goldstein, she was another stranger. He never saw her face. As he later wrote in his confession: “I felt a sensation, like something was entering me. . . . I got the urge to push, shove or sidekick. As the train was coming, the feeling disappeared and came back. . . . I pushed the woman who had blond hair.”

A Confidential Case

Because of patient confidentiality laws, Andrew Goldstein’s 3,500-page psychiatric file will never become public, even when he goes to trial on the murder charge. But it was given to me by people who see his treatment record as a harrowing testament to the failures of the mental-health system.

There is a long list of institutions and individuals who should be held accountable for what happened to Goldstein and Webdale, but at the top of that list belong Governor Pataki and the State of New York, for it is the states that, for the last 150 years, have had primary responsibility for citizens who are seriously mentally ill, and it is the states, beginning with deinstitutionalization in the 1950’s, that have persistently shirked that responsibility.

With the introduction of antipsychotic medication, state hospitals nationwide began releasing patients into the community. There was a good deal that was hopeful about this; by then, many state hospitals had become snake pits. Yet the states never created the outpatient services that were supposed to replace those hospitals, landing many of the seriously mentally ill on the streets. In 1953, there were 93,000 patients in New York’s state mental hospitals; today, the number is 6,000 and dropping. And while these last patients are often very troubled (about one-quarter have criminal backgrounds), the state’s special discharge teams continue to push them out the door — even when there’s no place for them to go. The New York State Office of Mental Health provides only 21,000 supervised community beds. And during Pataki’s first term, the state financed just 200 new beds with 24-hour supervision.

The problems in New York are the problems in virtually every state. Fewer than half of the Americans with schizophrenia receive adequate care, according to a 1998 national study.The Bazelon Center for Mental Health Law estimates that spending by the 50 states on treatment for the seriously mentally ill is a third less today than it was in the 1950’s (once numbers are adjusted for inflation and population growth).

While this is a danger primarily to the mentally ill and their families, who bear the brunt of the states’ neglect, it is also a danger to the public. From the many studies on mental illness and violence, we know that treated mentally ill people living in the community are no more a risk than the general population. But if a person is off medication and psychotic, he becomes a greater risk for violence; if you add substance abuse to that psychosis, the risk grows significantly, and one of the strongest predictors of whether a mentally ill person will be violent is whether he has been violent before.

It is the most sensational cases of the untreated-turned-violent that make headlines: Russell Weston Jr., ruled incompetent to stand trial for killing two U.S. Capitol police officers; Sergei Babarin, who murdered a man and a woman at a Mormon library in Utah; John Salvi 3d, who shot to death two abortion-clinic workers in Brookline, Mass.; Mark Bechard, judged criminally insane for killing two nuns in Maine, and last month, another New York subway case, Julio Perez, charged with attempted murder for pushing a father of three in front of a rush-hour train, severing the man’s legs.

Even in such criminal cases, the failings of the mental-health system are rarely exposed because most psychiatric records never become public. A few examples among many I looked into: in February, newspapers reported that Calvin Bostick, a homeless man, was arrested for setting fire to the Church of St. Anthony of Padua in Queens. But only from confidential state documents would you learn that between 1967 and 1998, Bostick had been treated and released 25 times from five state psychiatric institutions. And when he was out in the community, he built a criminal record of 18 convictions — for arson, assault, robbery and drugs.

When Kaid Farhn was arrested in December for nearly choking to death a 3-year-old girl standing with her mother in a Brooklyn subway station, it did not make news. He was recently found unfit to stand trial and confined for treatment — the second time in two years. In 1997, Farhn was arrested for assaulting three people, judged unfit and sent to the state psychiatric hospital on Staten Island, where, according to state documents, he was released after three weeks.

There are now far more mentally ill in the nation’s jails and prisons (200,000) than in state hospitals (61,700). With 3,000 mentally ill inmates on Rikers Island, the New York City jail is now, in effect, the state’s largest psychiatric facility. In a year’s time, according to a study by the Urban Justice Center, 15,000 prisoners in Rikers are treated for serious mental illness.

Some, like Goldstein, are awaiting trial on violent crimes. But far more have been too sick to cope alone in the community and were arrested for shoplifting, disturbing the peace, public lewdness, intoxication, drug use, fare-beating. Many would never have landed behind bars if there were adequate community care.

And that is the larger, quieter scandal behind the states’ failure. While some of the untreated are dangerous, far more suffer unnecessarily from their own illnesses. After years of declining numbers, the population of homeless adults is rising again in New York City shelters; it is estimated that of the 7,200 homeless, 2,200 to 3,000 are mentally ill. These days, commuters are noticing more disoriented people begging on the city’s subways; police precinct commanders report a growth in “E.D.P.” (emotionally disturbed persons) cases. “The number of disturbed people out there is definitely creeping back up,” says Mary Brosnahan, director of the Coalition for the Homeless in New York City.

A Return to the 1840’s

On a winter’s night, I visited the city’s Atlantic Avenue shelter in Brooklyn — a run-down, dark, drafty military armory that houses 300 men. It is a mean, hard place; the previous shelter manager was assaulted there and never returned to work. Everywhere disoriented men were talking to themselves, staring into space, rocking back and forth, their faces hidden like shades in hooded sweatshirts. A man with mangy hair, a foul smell and red plaid pants walked up to a top-ranking city official and explained that he was Albert Einstein. “I’m paranoid,” Einstein said. “I think I did something I didn’t do.”

To Muzzy Rosenblatt, then the city’s Acting Commissioner of Homeless Services, it is the mental-health system that seems crazy. “We shouldn’t have mentally ill people in our shelters,” he says. “They should be in mental-health programs.”

The state’s Commissioner of Mental Health under Governor Pataki is James Stone, and advocates for the mentally ill have been so frustrated by his department’s failure to finance more community-housing programs these last four years that they bitterly refer to this period as “the Stone Age.” Indeed, in some ways we are back to where we were in the 1840’s, when the legendary reformer Dorothea Dix set out to shame Massachusetts legislators into doing something for the mentally ill, who were locked away in the basements of local almshouses and jails. In 1843, Dix completed a 32-page expose, “Memorial to the Massachusetts Legislature”: “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth in cages, closets, stalls, pens! Chained, naked, beaten with rods and lashed into obedience!”

Dix described the care of each mentally ill person she had seen: “Saugus poorhouse: Apartment entirely unfurnished; no chair, table, nor bed … cold very cold. … On the floor sat a woman, her limbs immovably contracted, so that the knees were brought upward to the chin; the face was concealed, the head rested on the folded arms.” Her accounts reminded me of the basement apartment in Brooklyn where Andrew Goldstein lived last year, as described in Jamaica Hospital records: “One-room unit, nonfunctioning bathroom, unsafe electrical wires hanging from ceiling, no electricity, foul smell of dead and decaying mice, lock to room broken. In general, conditions unsuitable for living.”

Though a moralist, Dix understood that it was all about money, as David Gollaher points out in his biography of her, “Voice for the Mad.” The 1840 Massachusetts census counted 978 “lunatics”; the two state asylums had only 353 beds. The state, Dix implored, must appropriate $60,000 to create beds for the 625 neglected; cities and towns were too small and too poor to finance their own asylums, she argued. Shamed into it, Massachusetts found the money. And that was what cemented the states’ responsibility for the seriously mentally ill.

One hundred and fifty years later, neither the Giuliani administration nor the nonprofit agencies that rely on state funds to provide housing for the mentally ill have been able to shame Pataki into doing the same for them. The Republican Mayor is no Dorothea Dix, but Rudolph Giuliani does understand the problems of having lots of disoriented people on the streets and subways in a city where so many live so close together. Two years ago, he asked the Governor to renew a 1990 housing agreement for the mentally ill between the city and state, known as New York/New York. That agreement, made between Gov. Mario Cuomo and Mayor David Dinkins, provided 3,600 new units of housing for the mentally ill in the city, with the state financing two-thirds and the city the remainder. It had a big impact. At the time, there were 9,300 adults in city homeless shelters. By the mid-1990’s, when the New York/New York beds were opened, the shelter census dropped to 6,000.

But those beds are full now, the homeless population has risen and so the Mayor asked this Governor to help create New York/New York II. Giuliani was willing to put in $85 million for new construction — to match the city’s 1990 share — and hoped that Pataki would create a new program on the scope of the first.

Not this Governor. For two years those New York/New York II talks were stalled, with Pataki unwilling to commit more than $45 million for construction — a third of what city officials say was needed. This despite personal appeals to the Governor from an array of prominent New Yorkers, including John Cardinal O’Connor. Finally in mid-April, the Mayor gave up on the Governor’s doing more and put the best face on a watered-down agreement. In the end, for the state’s share, Pataki agreed to build just 500 new supervised S.R.O. beds over five years — on top of the mere 200 already in the state budget; in contrast, during Cuomo’s last five years, the state financed or pledged 3,200 such beds. As one Giuliani aide told me: “A long time ago we realized we weren’t going to get a lot from this Governor. He just wasn’t into it. So we were happy to get anything.”

In 1990, when the first New York/New York agreement was signed, advocates celebrated. This time they held a protest rally, on April 29, picketing Governor Pataki’s New York City office. “Pataki where are you?” chanted the 500. “Remember the homeless!”

A Broken Contract

Neither Governor Pataki nor Commissioner Stone would be interviewed for this article, and the spokesman for the state Office of Mental Health, Roger Klingman, requested written questions and supplied written responses. He would not comment on the Goldstein case, because “state mental-hygiene law does not permit us to discuss information from a patient’s clinical record.” He described the state system as “large and varied,” and wrote that New York’s community housing program is “one of the largest if not the largest such system in the country.”

Unfortunately, there are no comparative qualitative studies of state systems, and efforts to create national standards are in the early stages, says Clarke Ross, a public-policy expert at the National Alliance for the Mentally Ill. However, Ross says, any such measure would include the numbers of mentally ill in jails and prisons, as well as homeless, and in those areas, New York also has the dubious distinction of being a leader.

One measure of how low the national standard is when it comes to caring for the seriously mentally ill is to compare their deinstitutionalization with the movement of mentally retarded adults into the community during the same period, which is one of the more impressive social revolutions of our time.

In the early 1970’s, after Geraldo Rivera sneaked a camera into the Willowbrook state institution for the mentally retarded on Staten Island, exposing snake-pit conditions, family members sued. Gov. Hugh Carey could have got the state off cheap by agreeing to improve Willowbrook, but instead signed a consent decree that forged a remarkable social contract for the mentally retarded: for each person discharged, the state would finance a group home or an apartment bed. That compassionate agreement helped to set a national standard.

By 1998, the state had financed 32,000 community beds for the mentally retarded — even though those beds are two to three times as costly as the 21,000 available to the mentally ill. (Mentally retarded residents need far more staff support.) Although Pataki hadn’t come close to matching his predecessors — the list of mentally retarded adults in New York waiting for housing grew to 6,000 by last year — he has always at least paid lip service to the social contract forged by Carey, building the mentally retarded between 480 and 1,100 new community beds each year.

Then last June, just as Pataki’s re-election campaign was getting under way, newspapers in suburban Westchester County reported that there were 26 mentally retarded adults found living in homeless shelters there — prompting outrage. Pataki’s response was swift. Ten weeks before the election, he suddenly announced a program to finance 5,000 new community beds for the mentally retarded called New York Cares. It means that community beds built or pledged for the mentally retarded now outnumber those for the mentally ill by some 15,000. Indeed, the Governor’s 1999 budget calls for a $40 million increase in spending for the mentally retarded; for the mentally ill, a $27 million cut.

Why haven’t we forged the same social contract for the mentally ill? After all, there are as many as 3,000 mentally ill in New York City’s shelters. One reason has to do with timing. In the mid-1970’s, when Governor Carey signed the Willowbrook consent decree, there was already a well-organized lobby for the mentally retarded. But the mentally ill had no lobby yet; the National Alliance for the Mentally Ill, which today boasts more than 200,000 members, was not founded until 1979. It wasn’t until the mid-1980’s, after deinstitutionalization had created a large, menacing homeless population, that New York began financing a substantial number of community beds for the mentally ill. But by then, the Reagan revolution had set in, activist judges were no longer in favor and government spending for the poor was in decline. Just as new community-housing programs were showing real success, money was drying up and advocates couldn’t find a judge or governor to forge that social contract for the mentally ill.

In the early 1990’s, I spent two years all but living at a well-run, state-financed group home for a book on the mentally ill. What I saw made me a believer in quality community programs and in the nonprofit agencies that use state money to run them. There were problems at the home, but they did not spill into the streets, because counselors were there to defuse the crises.

Today there is an impressive array of state-financed community models, from the heavily regimented to the lightly supervised, that have been developed by nonprofits: group homes for mentally ill substance abusers that use an abstinence model and have 24-hour supervision; S.R.O.’s, where people have their own rooms, share kitchens and get support from caseworkers and psychiatrists with offices on the premises; rent-subsidy programs to pay for an apartment in an affordable building in the community, with a case manager who might visit as often as every day or as rarely as once a month.

The programs are so varied because the needs of the mentally ill vary, too. Among the least restrictive is Pathways to Housing, a program based in Harlem and Queens, which gives homeless mentally ill people who have long resisted treatment apartments even if they still have a drinking or drug problem and do not want to take medication. They are assigned a case manager who sees them regularly, making sure their problems with meds or substance abuse are reasonably under control. Though many Pathways residents had been homeless for more than a decade, 88 percent were still housed in this program after five years.

Thayer Gamble, 43, is one. Talk about a time bomb: he is schizophrenic, was suicidal, used crack and has been imprisoned several times. Four years ago a hospital social worker referred him to Pathways, which gave him an apartment and a caseworker, Ben Tallerson. Tallerson visited Gamble’s Harlem apartment regularly. Because Tallerson knew Gamble, he realized one reason Gamble had trouble taking his medication properly. “He can’t read,” Tallerson says. “He didn’t know what it meant to take meds A.M. and P.M.” Tallerson drew it out for him, the sun for A.M., the moon for P.M. And two years ago, when Gamble started on crack again, Tallerson noticed. “When Thayer’s going good,” he says, “he has clean habits, he keeps himself clean, his apartment is clean. Now I start seeing his physical appearance is sloppy, he’s smelly, he’s hanging on the streets.” Tallerson urged him into a detox program. As Gamble says, “I have his beeper number — if I’m having a problem at 3:30 in the morning, I can call Ben.”

here are thousands of mentally ill New Yorkers whose lives are better because of state-financed programs like Pathways — it’s just that success is less visible than failure. Cecil Dozier, 44, panhandled at the corner of Bleecker and Thompson in Greenwich Village last fall. He is now in a program for mentally ill substance abusers run by Volunteers of America. Bladimer Lopez, who slept by the Dumpster at a McDonald’s on 125th Street, is in a supervised S.R.O. for the mentally ill run by the Center for Urban Community Services. So is Robert Whynot, who used to beg on the subways until he made $35, then bought himself a bag of heroin, half a gram of coke and a metro card (“so I wouldn’t get arrested for fare-beating”). Now for the first time, at 40, he is getting treated for manic depression.

Even the New York City shelter system has made considerable progress, converting 1,000 shelter beds to mental-health-service beds run by nonprofits. These community programs cost between $10,000 and $43,000 per person, per year. All, however, are cheaper than a year at a state hospital ($135,000) or Rikers Island ($69,000).

The Push to Discharge

In 15 years of reporting on mental health, I have never seen the system in such disarray. Unprecedented cost-cutting measures are undermining safety valves that had long been in place. I count six dangers — for the mentally ill and the public — that have come into play in the last few years.

Danger 1: The last 6,000 long-term hospital patients that the state is working so hard to discharge are twice as likely to have a criminal background as patients from a decade ago.

Danger 2: While many of these patients could live in 24-hour supervised community residences, those beds are full. Even if the first New York/New York II beds open as scheduled, more than a year from now, there won’t be anywhere near enough to absorb these new discharges, let alone the growing number of homeless.

Danger 3: Psychiatric wards of general hospitals used to have the flexibility to keep a patient like Goldstein for months or transfer him to a state hospital for long-term care. But state hospitals are now taking few admissions, and managed care is pressing the general hospitals to discharge within three weeks. The five acute-care hospitals that treated Goldstein can receive up to $700 a day during those first weeks. But after that the medicated schizophrenic is usually considered “stable” by insurance monitors, and compensation can drop to $175 a day or be denied altogether. And even at $175 per day, hospitals lose money. As a result, there is a revolving door for patients, who quickly relapse without community support.

Danger 4: There are a record number of mentally ill in prisons and jails now being released — without any discharge planning.

Danger 5: The crackdown on Federal disability and welfare benefits will leave more mentally ill people with no Government support.

Danger 6: Government watchdog agencies like the Commission on Quality Care for the Mentally Disabled in New York have had their budgets cut and their jurisdictions narrowed in recent years. Over the last decade, the commission’s staff has been reduced 25 percent. It is far less likely today to undertake major inquiries. During Cuomo’s adminstration, the Legislature authorized the commission to do a sweeping investigation of the adult-home industry; that authorization has not been renewed.

he reason the mental-health system behaves so irrationally is usually money. There is a push to close state hospitals because that saves money, but there is no incentive to build the badly needed community housing to replace them because that costs money.

The Pataki administration has given each state hospital an annual census-reduction goal. Mimi Koenigsberg was a social worker at Manhattan Psychiatric Center for 24 years, and in that time she never saw a push for discharges like the one begun in early 1998 by the hospital’s director, Eileen Consilvio. “We started having these weekly discharge meetings,” Koenigsberg recalls. “She’d say: ‘Why isn’t so-and-so going, he’s been ready for weeks; this one’s been ready for months. … Just get them off the census.”‘

Klingman, the state mental-health-office spokesman, says that these meetings are conducted “to assure that discharge planning is proceeding appropriately.” But the process plainly worried doctors at the Manhattan state hospital, where more than half the patients have a criminal record. According to minutes of a March 17, 1998, meeting of the psychiatry staff, “In the need to reduce census it appeared to some present that they were being ordered by nonmedical staff to discharge patients prematurely.”

A measure of how difficult these last patients are and how indifferent the state can be came in the form of a December ruling, by the New York State Labor Department, that Hudson River Psychiatric Center in Poughkeepsie is a hazardous workplace. It was the first such ruling in state history. While Klingman dismisses the case as a union ploy, the Governor’s own labor department noted that state “employees have suffered broken bones, bites … and have been choked until they were unconscious” by patients. The report said that most injuries to workers came when wards were below minimum staffing levels.

In one case, a single patient assaulted aides and nurses 37 times over two months. The local union president, Judy Watts-Devine, repeatedly asked James Regan, the hospital director, to transfer the patient to a high-security facility for violent cases, but was ignored. And then Mary Veltre, a nurse, became the 38th case: she was kicked in the pelvis and taken to a local emergency room. At that point, Watts-Devine told the director, “I’m going to call every TV station and every newspaper unless you get this man out of here.” And he did.

Still, in the next few years, the state hopes to reduce its long-term census from 6,000 to as low as 3,700. With so much pressure from Albany to release, discharge teams routinely mislead the nonprofit housing providers about the severity of patients’ problems, in hopes of arranging a placement quicker, in a less supervised setting, no matter how inappropriate. The Colonial is a run-down hotel on 112th Street in Manhattan. Colonial tenants complain of filthy, smelly conditions, fights in the narrow hallways and people living crowded into small rooms. Rockland Psychiatric Center acknowledges discharging 75 to 100 patients to the Colonial in recent years. Elizabeth Kane, a tenants’ lawyer for the Goddard Riverside Community Center, called Rockland at one point to complain. “I didn’t know if they realized what a dangerous, stupid place it was to send a fragile person,” she recalls. “They said, ‘We know, but we don’t have any choices.”‘

Even the building manager, John Klein, who denies tenants’ complaints, says: “I don’t think you’d want to live in a building like this. The problem is, there’s no place for these people.”

On Dec. 30, 1998, Rockland discharged a 43-year-old man to the Colonial. His sole support was a case-management team. Diane Sonde, who oversaw it, argued that the man needed a 24-hour supervised residence. Rockland disagreed.

The state never told Sonde’s team key details of the man’s history: that he was so sick that he had been in state hospitals 32 of the last 34 years; that he had a history of sexual assault; that he had been transferred to a high-security state facility four times because he was too dangerous for a regular state hospital.

After a few days at the Colonial, the man cornered a woman on Sonde’s team, sexually exposed himself and threatened her. He was immediately returned to Rockland. Only then did Sonde begin to piece together his real story. Nor was it the first time that the state had tried dumping this troubled man: in August 1998, Rockland discharged him to a city homeless shelter, only to have him walk back into a city hospital two days later, asking for help.

It is not that community programs won’t take tough cases but that they want adequate resources from the state. A few years ago, Kingsboro Psychiatric Center in Brooklyn sent a man to a discharge interview at the Institute of Community Living, a large nonprofit housing agency. The state’s two-page summary mentioned that the man had previously tried suicide. What the state summary did not mention was that the suicide attempt came after the man murdered his father. The community program learned this while interviewing him and confronted state officials, and he was returned to Kingsboro. Klingman claims that Kingsboro officials didn’t know the man had committed a murder because it was part of his juvenile record and was sealed. In a year, Kingsboro tried again, but this time the nonprofit agreed to take him only if he was in a 24-hour supervised residence with an intensive-case manager. And the state agreed.

All the big nonprofit community providers say the same thing: they can’t trust state hospitals to tell the truth. “They mislead us,” says Steve Warren, director of Services for the Underserved, a nonprofit with 800 state-financed beds. “They’ll fudge on people with arson and sexual crimes. They’re trying to package them in the best way they can, to get them out.”

An Unnecessary Death

The sad saga of a schizophrenic 51-year-old named Peter Fazio, a long-term patient at Manhattan Psychiatric Center, illustrates the consequences of the state’s relentless push to discharge. Before his schizophrenia hit, in the 1960’s, Fazio was an A student at Bergen Catholic in suburban New Jersey and won a full scholarship to Manhattan College. After the illness, he was wild. He was estranged from his family, at one point holding his mother hostage for five days before police arrested him. He lived in Bowery flophouses until he murdered another resident, suffocating the victim by shoving a sock into his mouth. At the time, the police were struck by how much other flophouse residents despised Fazio.

In jail, he stopped eating and was kept alive by a feeding tube. At Attica prison, he tried hanging himself in 1986. For the next two years, he later told a therapist, he planned how he would kill himself after his prison discharge. In May 1988, two days after that release, he slit his chest open with a scalpel, then stuck a boning knife into his heart. Miraculously, he lived, and was sent to Manhattan Psychiatric, where he spent the next 10 years. While still a troubled patient — records describe him as “sadistic” and “hostile” to fellow patients, as repeatedly pacing the halls, paranoid and arrogant — for the first time, he found a niche. He relished waking early to read the newspaper, sold bread from a little cart, got along with staff members and enjoyed grounds privileges.

When discharge was discussed, he commented, “There’s nothing more to enjoy outside.” When pressed, he repeatedly threatened suicide. A social worker’s note describes a talk in January 1997 about discharge: “I asked about suicide. He said, ‘Yeah, I’d basically go that route.”‘

Hospital officials were well aware that Fazio had repeatedly threatened suicide if released. “When discharge planning is discussed,” says a May 1997 note, “Fazio retreats.” The note continues: “I will hurt myself.’ Alert: He is a serious risk.”

In the months leading to his final night at the hospital, July 26, 1998, Fazio “complained he and other patients are being pushed by the administrattion to be discharged whether they are ready or not,” according to records. During therapy he asked, “Is the reason they’re pushing discharge now that they want to save money?”

For a few months, the record indicates, he was more positive about leaving, but by spring 1998, as the staff pressed, he is described as “depressed” and “not very happy or ready to talk about discharge.” He worried that people in the community would know he was a murderer. In May, he told a case manager that twice before at the hospital he had tried suicide but had mentioned it to no one. Still the staff pressed, and on June 3 a discharge team, sent to the hospital by the state to lower the census, indicated that Fazio was ready to go.

On July 6, he was taken to visit a community residence, though he refused a placement there. On July 12, an aide noted his “regression” and “isolation,” and a July 22 note mentioned his ambivalence and fear. On July 25, his next to last night at Manhattan Psychiatric, he stayed in his room at dinnertime, according to a hospital worker I interviewed: “He says, ‘I’m being discharged, I really don’t want to leave.’ He was very depressed.”

The next evening, Fazio again did not go to dinner, but this time was found in the bathroom, “in a pool of blood,” a final hospital note says. “Body was cold to the touch.” Using a razor, he had cut a wedge out of his neck, piercing his jugular.

The story has an addendum. The state’s quality-care commission did a brief report on Fazio’s suicide, finding “no deficiencies” by the hospital. The report said, “We found no evidence that Mr. Fazio had threatened suicide since mid-1996” (though in Fazio’s hospital notes I count seven suicide threats in 1997 alone). The report found “nothing significantly unusual in the life of Mr. Fazio in the weeks or days prior to his death” and concluded that Fazio’s death was “unpredictable, thus not preventable.”

The report offered no theory as to why Fazio did kill himself. However, it did mention that two hospital workers who had talked to the media were disciplined for violating the confidentiality of the dead man.

Off the Streets

Rockaway, Queens, is a shabby seaside resort of old boarding houses and for-profit adult homes that have long been a dumping ground for the state’s mental hospitals. Jonathan Gaska, district manager for Rockaway’s community board, has been fighting the problem for years. “There’s no supervision — you have sick people urinating on the lawns,” he says. “We have a guy who walks around with a mop on his head. You feel sorry for people like that. They act odd, they dress odd and they hang around outside all the time — it keeps people away.” To discourage the mentally ill from sitting on the benches in front of the Park Inn adult home, the benches were removed. Now the mentally ill stand in front of the Park Inn.

A few years ago, Steve Warren, the director of Services for the Underserved, offered to take over a particularly bad adult home and run it properly. He took civic leaders to see housing programs that he ran all over the city. “They were good,” Gaska says. “Warren was so open. Everyone’s like, ‘What’s the deal?’ We’re always being lied to.” When Warren started to redesign the Rockaway adult home, he spoke to the home’s residents about why they were always on the street. “You know why?” Warren recalls. “There were 125 people crowded in that adult home, two or three to a room. To get privacy, the street was the only place to go.”

With a $1.2 million state grant, he redesigned the place, reducing the size to a 71-bed S.R.O. where everyone has a small apartment. There are also several lounges and recreation areas. The state provided financing for an extensive staff, including eight case managers, two substance-abuse counselors, a psychiatrist and a nurse. The facility costs the government $25,000 per person, per year, three times the subsidy for one of those awful adult homes.

“The place is as good as advertised,” Gaska says. “The state has to be able to make other places do what they’re doing.”

nce, for a year, in 1994, Andrew Goldstein was in a group home on the grounds of Creedmoor state hospital and did well, regularly taking his medication. 8/17/94: Follows schedule well, is uniformly polite, friendly and cooperative. But that group home is highly supervised, costing $41,600 per person, per year, and there is great pressure for state workers to move residents on to less-supervised, less-expensive programs, even if it’s too soon.

A state discharge team set up screening appointments for Goldstein at a few apartment programs that offered moderate supervision. But he was judged too low-functioning and didn’t pass those interviews. A system driven by an individual’s well-being would let him stay at the Creedmoor home and try again later; a system driven by money cannot wait. So when he wasn’t well enough for a program with moderate support, the team pushed him to move to a place with almost no support, an adult home.

oldstein rejected the first adult home he was shown as too large, a 200-bed facility in Rockaway, but social workers kept pressing. 10/31/94: He has been told he cannot go to Delaware to visit his father until his housing placement is made. So he chose the very next thing he was offered, Leben Home in Queens, with 361 beds, the second-largest adult home in the state. For Goldstein, that was the beginning of the downward spiral to the basement apartment and Webdale. He tried several times after that to get back into a supervised residence, including the one at Creedmoor, where he had lived in 1994, but with no luck.

On Sept. 12, 1997, after Goldstein walked into Bellevue Hospital’s E.R. seeking help, a hospital social worker noted: “Patient states he would like to return to S.C.C.R.” — the group home — at Creedmoor. Spoke with Carol Erman, the secretary, who states patient was a resident, however, he can only be referred from Creedmoor inpatient. She referred patient to David Frazier for community residence. Mr. Frazier reviewed chart but was unable to accept referral as there were no beds available.”

The next day, Bellevue discharged Goldstein to his basement apartment. The social worker noted that she had given him a piece of paper with the phone number of a mobile crisis unit to call if he became disoriented again; the social worker also noted that he had no phone.

or years, instead of resources, there have been shortcut solutions that push the problem around. The latest, inspired by the Goldstein case, is an effort to pass an outpatient commitment law for New York. It would allow people resistant to treatment to be committed to a supervised community program, and if they are not compliant with medication, they would be hospitalized. Supporters see it as a way to control the resistant mentally ill and leverage the system for more resources; if more people are committed to community programs, the state will have to build more. Opponents fear it will deprive the mentally ill of the right to control their treatment.

I doubt it would make much difference either way. The reality is that commitment is no longer much of a civil liberties threat — state hospitals don’t want patients, and the short-term hospitals can’t get rid of them fast enough. If New York had outpatient commitment, it probably would not be enforced because the resources aren’t there; or if it were enforced, given current resources, one group of people that needs care would be pushed aside for another group that also needs it. There are 37 states with outpatient commitment laws, and most have systems as dysfunctional as New York’s.

What I found most haunting about Goldstein’s 3,500-page file was his repeated pleas for services that had no vacancies. There was no room at the inn.

Last month at a court hearing, Goldstein’s lawyers, Harvey Fishbein and Jack Hoffinger, argued that he was not fit to stand trial. Judge Carol Berkman disagreed, finding him competent. But she also hinted that she understood the larger scope of the crime. “I have no doubt,” she said, “that someday, probably after we are all gone, people will look back at our treatment of mental illness under the law and be shocked and appalled.”

When Dorothea Dix had finished shaming Massachusetts into spending more money, she set off to shame New York. In her 1844 report to Albany’s legislators, she urged them to live up to the state motto, “Excelsior! Excelsior!”

Excelsior is probably shooting a little high when it comes to social services in America these days, but the time is long overdue to establish a social contract for the mentally ill.

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